Revision Box Surgery

SECTION 10: EMQ REVISION
BOXES
The following boxes are directed towards revision for
extended matching questions. They concentrate on particular
collections of symptoms/signs or phrases to look out for in ques-
tions. Answering EMQs is considerably aided by pattern recogni-
tion, and we hope reading through these boxes encourages you to
think along those lines in addition to providing information.
1 Abdominal pain
2 Weight loss
3 Hepatobiliary surgery
4 Signs of chronic liver disease
5 Paediatic surgery
6 Surgical radiology
7 Inflammatory bowel disease
8 Skin lesions
9 Thyroid malignancy
10 Thyroid disease
11 Urology investigations
12 Renal calculi
13 Lump in the groin
14 Dizziness/vertigo
15 Sore throat
16 Dysphagia
17 Neck lumps
18 The paediatric hip
19 Upper limb nerve injury
20 Lower limb nerve injury
21 Reflexes and motor nerve roots
22 Upper limb orthopaedic conditions
23 Lower limb orthopaedic conditions
24 Red eye
25 Retinal signs
26 Pupils
27 Ocular movements
28 Visual field defects
29 Hypertensive retinopathy
30 Diabetic retinopathy
31 Neurosurgery/head injury
32 Arterial blood gases
33 Classical EMQ descriptions of blood gases
34 Skin cover
10 EMQ revision boxes
Abdominal pain
Box 1 lists the classical abdominal pain descriptions that come up in EMQs.
Box 1 Abdominal pain descriptions
Description Problem
Colicky loin pain radiating to groin Ureteric colic

Constant right upper quadrant pain Biliary colic
jaundice
Severe epigastric pain radiating to back Acute pancreatitis
Associated with vomiting
History of gallstones/qqalcohol
Periumbilical pain radiating to right iliac fossa Acute appendicitis
Central abdominal pain, expansile pulsatile Abdominal aortic aneurysm
mass
Iliac fossa pain, positive pregnancy test Ectopic pregnancy
Severe abdominal pain with rigid abdomen Perforated viscus
Weight loss 249
Weight loss
As shown in Box 2, weight loss is a classical soft sign towards malignancy in
an EMQ.
Box 2 Some associations between weight loss and malignancy
Symptoms Malignancy
Weight loss, anaemia, dysphagia Oesophageal carcinoma

Weight loss, painless obstructive jaundice Pancreatic head carcinoma
Weight loss, haemoptysis, smoker Bronchial carcinoma
Weight loss, painless haematuria Bladder carcinoma
Weight loss, change in bowel habit, rectal bleeding Sigmoid/rectal carcinoma
Flushing, abdominal pain, diarrhoea, heart failure Carcinoid syndrome
Hepatobiliary surgery
The two conditions in Box 3 are frequently confused with each other and commonly
crop up in EMQs.
Box 3 Primary biliary cirrhosis and primary sclerosing cholangitis
Presentation Condition
Middle-aged woman presents with: Primary biliary cirrhosis

Pruritus, jaundice, pigmentation
Antimitochondrial antibody positive
Associated with:
Rheumatoid arthritis
Sjgrens syndrome
Thyroid disease
Keratoconjunctivitis sicca
Renal tubular acidosis
Membranous glomerulonephritis
Usually middle-aged male: Primary sclerosing

Pruritus, jaundice, abdominal pain cholangitis
qALP, antimitochondrial antibody negative
Associated with inflammatory bowel disease (esp. UC)
Chronic liver disease 251
Chronic liver disease

Box 4 gives some examples of signs of liver disease particularly relevant to EMQs.
Box 4 Signs of liver disease
Clubbing
Flapping tremor
Dupuytrens contracture
Palmar erythema*
Gynaecomastia
Spider naevi*
*denotes signs that also occur in acute liver disease
Chronic liver disease associated with:

Early-onset emphysema -1 antitrypsin deficiency
Pigmentation, diabetes Haemochromatosis
Dysarthria, dyskinesia, dementia, Wilsons disease
KayserFleischer ring
Paediatric surgery
Look out for the features in Box 5 in EMQS concerning paediatric surgical
presentations.
Box 5 Paediatric signs
Condition Feature
Pyloric stenosis Projectile vomiting

Right upper quadrant mass
Intussusception Redcurrant jelly stools
Hirschsprungs disease Failure to pass meconium, distended
abdomen
Absence of air in rectum
Duodenal atresia Bilious vomiting
Double bubble on x-ray
Surgical radiology 253
Surgical radiology
Box 6 shows phrases to look out for describing x-ray features in EMQs.
Box 6 X-ray features
X-ray feature Condition
Free air under diaphragm Perforated viscus (e.g. diverticulum/

duodenal ulcer)
Sentinel loop Acute pancreatitis
Inverted U loop Sigmoid volvulus
Loss of haustral pattern Ulcerative colitis
Cobblestoning Crohns disease
Apple-core lesion Carcinoma of colon
Inflammatory bowel disease

Crohns disease and ulcerative colitis are the two major forms of inflammatory
bowel disease. There is significant overlap in the clinical features of these diseases.
Box 7 summarizes typical presentations and highlights differing features that are
likely to be mentioned in EMQs.
Box 7 Crohns disease and ulcerative colitis
Can affect anywhere between mouth and anus Crohns disease

Skip lesions
Weight loss, diarrhoea, abdominal pain
Strictures, anal fistulae
Barium enema:
cobblestoning, rose-thorn ulcers
Granulomas
Only affects colon Ulcerative colitis

Continuous disease
Diarrhoea with blood and mucus
Fever, tachycardia, toxic megacolon in
severe acute UC
Barium enema:
Loss of haustra
Sigmoidoscopy:
Oedematous, friable mucosa
No granulomas
Skin lesions 255
Skin lesions
Look out for particular phrases in questions describing skin lesions. The descrip-
tive features in Box 8 direct you to the likely diagnosis.
Box 8 Characteristic skin lesions
Skin lesion EMQ feature
Sebaceous cyst Punctum

Squamous cell carcinoma Everted edge, lymphadenopathy
Basal cell carcinoma Rolled, pearly edge
Keratoacanthoma Central necrotic core, horn projection,
spontaneous resolution
Ganglion Firm swelling moves with tendon
(often dorsum wrist)
Neurofibroma Causes tingling, may be multiple
Lipoma Lobulated, compressible mass
Keloid Lesion extending beyond scar
Melanoma Itchy, bleeding, changing shape/colour
Thyroid malignancy
Box 9 lists features to look out for in questions concerning thyroid malignancy.
Box 9 Features of thyroid cancer
Thyroid cancer Features
Follicular carcinoma Usually woman and solitary lesion

Haematogenous spread (e.g. bone)
Papillary carcinoma Often multifocal, early lymph node spread
Orphan Annie nuclei
Psammoma bodies
Anaplastic carcinoma Usually elderly
Aggressive, so may be rapidly growing mass,
airway compression
Medullary carcinoma May mention associated features of MEN
syndrome (e.g. phaeochromocytoma)
Lymphoma May mention general features: hepatomegaly,
splenomegaly, night sweats
Thyroid disease 257
Thyroid disease
Box 10 lists features to look out for in questions concerning thyroid dysfunction.
Box 10 Thyroid dysfunction
Thyroid condition EMQ features
Hashimotos thyroiditis Hypothyroid symptoms with goitre

(e.g. weight gain, bradycardia, constipation)
Lymphocytic, plasma cell infiltrate, follicles
Parenchymal atrophy
Graves disease Goitre, hyperthyroid, eye signs
(e.g. exophthalmos, lid lag)
Pretibial myxoedema
Endemic goitre Iodine deficiency, longstanding increased TSH
Rare in UK
De Quervains thyroiditis Tender thyroid, post-viral illness
Urology investigations
Box 11 lists common investigations that come up in EMQs.
Box 11 Urology investigations
Investigation Uses
USS Evaluation of hydronephrosis, hydroureter

and urinary tract stones
Fluoroscopy and video urodynamics Determines bladder, intra-abdominal and
urethral pressures
Cystourethroscopy Visual evaluation in cases of haematuria,
persistent postoperative incontinence, and
suspected cases of malignancy, fistula or
diverticulum
Intravenous pyelography Differentiates between ureterovesical fistula,
vesicovaginal fistula and ureterocoele
Positive-pressure urethrogram Diagnosing urethral diverticulum
MRI Visualizing pelvic floor defects
Renal calculi 259
Renal calculi
Box 12 lists the incidences and associations of renal calculi.
Box 12 Renal calculi
Calculus Incidence Associations
Calcium oxalate 75 per cent Alkaline urine

Disordered calcium metabolism
(e.g. hyperparathyroidism
Increased oxalate absorption
(e.g. Crohns disease)
Triple phosphate 15 per cent Alkaline urine
Urea splitting organisms
(e.g. Proteus)
Urate 5 per cent Acidic urine, gout
Cysteine 2 per cent Acidic urine, cysteine metabolism
disorder
Lump in the groin

In EMQ presentations of a scrotal/groin swelling, look out for the key features of
whether the swelling is distinctively testicular and whether you can palpate above
the swelling (see Box 13).
Box 13 Clinical testing of a lump in the groin
When assessing a Can you Can the testis Does the swelling Note:
scrotal swelling: palpate above and epididymis transilluminate?
the swelling? be palpated?
Hydrocoele Yes No Yes

Inguinal hernia Yes Yes No Cough impulse
Cord lipoma Yes Yes No Painless
Epididymal cyst Yes Yes Yes
Varicocoele Variable Yes No Bag of worms
Dizziness/vertigo 261
Dizziness/vertigo
Box 14 gives clues about assessing a patient presenting with dizziness.
Box 14 Testing for dizziness/vertigo
Diagnosis Duration Tinnitus Loss of hearing Precipitant factors

BPPV Seconds None None Specific head
movements
Menires disease Hours Unilateral Unilateral None
Vestibular neuronitis Days None None None
Acoustic neuroma Varies Unilateral, Gradual
persistent unilateral None
reduction
Sore throat
Sore throat has a number of causes, but Box 15 identifies the findings for various
conditions.
Box 15 Some causes of sore throat
Diagnosis General Speech Trismus Appearance Neck Bloods

malaise and
temperature
Quinsy Yes Hot Yes Unilateral palatal Enlarged qWCC,

potato swelling uvula nodes neutrophilia
displacement
Tonsillitis Yes Normal No Bilateral tonsil Enlarged qWCC,

swelling nodes neutrophilia
erythema
spotty white
exudate
Glandular Yes Normal No Bilateral tonsil Massive qWCC,

fever swelling white nodes lymphocytosis
membranous Paul Bunnell
exudate test positive
qLFTs
Acid reflux No Normal No Normal Normal Normal

oropharynx
Tonsil No Normal No Unilateral tonsil Nodal May be raised

carcinoma swelling/ mets may WCC
ulceration be present
Dysphagia
Dysphagia has a number of causes, but Box 16 identifies the findings for various conditions.
Box 16 Some causes of dysphagia
Diagnosis True Regurgitation Neck Referred Other

dysphagia of food swelling otalgia features
Pharyngeal Yes, progressive as Yes, typically Yes, if large No Diagnosis confirmed with barium
pouch pouch enlarges after minutes swallow
and undigested
Globus No No No No Anxiety, lack of positive findings

pharyngeus on examination and investigations
Hypopharyngeal Yes, gradually If large may be Yes, from Yes, via IX cranial In advanced disease, may present
carcinoma progressive from regurgitation metastatic nodes nerve with dysphonia secondary to vocal
solids to liquids cord palsy
Thyroid goitre Yes, if large No Antero-inferior, No Sudden increase in size and

moves on swallowing stridor: consider malignant disease
Oesophageal Yes, to solids and Yes No No Barium swallow typically shows bird-beak
achalasia liquids narrowing at gastro-oesophageal junction
Diffuse oesophageal Yes No No No Associated chest pain and corkscrew

spasm oesophagus on barium swallow
Bulbar palsy Yes No No No Poor cough dysphonia dysarthria

Neck lumps
Box 17 identifies lumps that are likely to be implicated in EMQs.
Box 17 Some cause of neck lumps
Diagnosis Site Moves on Moves on Other EMQ

swallowing tongue features
protrusion
Thyroid Midline lower Yes No Bruit on auscultation
swelling neck Signs of thyrotoxicosis
(e.g. atrial fibrillation,
tremor, eye signs)
Thyroglossal Typically midline Yes Yes May become infected

cyst region of hyoid, resulting in sudden
may be just lateral increase in size and pain
to midline
Branchial cyst Lateral neck just No No Transilluminates

anterior to May present in later life
sternocleidomastoid with infection
(junction of upper Position often characteristic
third and lower in question
two-thirds)
Chemodectoma Lateral neck, No No Pulsatile and mobile

bifurcation of laterally
carotid
Submandibular Below ramus No No Bimanually palpable

mandible Stone may be palpable in
submandibular duct
Marginal mandibular nerve
palsy in malignant cases
Parotid Parotid region, No No VII nerve palsy in cases of

but can occur at malignancy
angle of mandible
Cystic hygroma Posterior triangle No No Often young patient

Brilliant transilluminance
The paediatric hip 265
The paediatric hip

These always crop up in orthopaedic EMQs and are frequently mixed up (see Box 18).
Box 18 The paediatric hip
Condition Features
Congenital dislocation of hip Usually detected at birth by

Ortolanis/Barlows tests
May present later with delayed walking/
waddling gait
Extra thigh crease on examination
Perthes disease Usually male

Hip pain and limp (311 years)
X-ray: decreased size femoral head, patchy
density
Slipped femoral epiphysis Often obese

Older than Perthes patient (1016 years)
Groin pain, limp
Flexed, abducted, externally rotated hip
Upper limb nerve injury

Box 19 lists clinical features of some upper limb injuries.
Box 19 Upper limb nerve injury
Nerve implicated Features
Median nerve Wasting at thenar eminence

Loss of sensation, lateral palmar surface 312 digits
Test for weakness in abductor pollicis brevis
Frequently affected in carpal tunnel syndrome
Ulnar nerve Wasting at hypothenar eminence

Sensory loss over medial 112 fingers
Test for weakness in abductor digiti minimi
Claw hand deformity
Positive Froments sign
Radial nerve Weakness of wrist extension leading to wrist drop

Anaesthesia over 1st dorsal interosseous muscle
Axillary nerve Failure of abduction after shoulder dislocation

Anaesthesia over military badge area of shoulder
Long thoracic nerve Winged scapula
Klumpkes palsy (C8, T1) Paralysis of intrinsic muscles of the hand

Loss of sensation in ulnar distribution
Horners syndrome sometimes present
Erbs palsy (C5, C6) Loss of shoulder abduction and elbow flexion
Arm held internally rotated
Waiters tip sign if arm adducted behind back
Lower limb nerve injury 267
Lower limb nerve injury

Box 20 lists clinical features of some lower limb injuries.
Box 20 Lower limb nerve injury
Nerve implicated Features
Common peroneal nerve Often, blow to lateral aspect of knee is described

Weakness in dorsiflexion and eversion of foot
Sensory loss over dorsum of foot
Tibial nerve Inability to invert foot or stand on tiptoe
Sciatic nerve Foot-drop (e.g. after hip replacement)

Sensation loss below knee, except medial lower
leg (saphenous nerve)
Reflexes and motor nerve roots

EMQs often delineate focal weakness/loss of reflexes to identify nerve/root lesion
(see Box 21).
Box 21 Nerve roots
Reflex/movement Nerve root
Supinator C5, C6
Biceps C5, C6
Triceps C7
Knee L3, L4
Ankle S1
Shoulder abduction C5
Elbow flexion C5, C6
Elbow extension C7
Finger abduction T1
Hip flexion L1, L2
Hip extension L5, S1
Knee flexion L5, S1
Knee extension L3, L4
Ankle dorsiflexion L4, L5
Ankle plantar flexion S1
Upper limb orthopaedic conditions 269
Upper limb orthopaedic conditions

Box 22 will help in the diagnosis of conditions of the upper limb.
Box 22 Orthopaedic conditions of the upper limb
Clinical signs Diagnosis
Thickening, fibrosis palmar fascia Dupuytrens contracture

Dinner fork deformity Colles fracture
Wrist pain on forced thumb adduction, flexion De Quervains syndrome
Pain, paraesthesia with median nerve distribution Carpal tunnel syndrome
Shoulder pain on abduction 60120 Painful arc syndrome/supraspinatus
tendonitis
Lump in upper arm after lifting Ruptured long head of biceps
Reduced active/passive movement, stiffness of Frozen shoulder/adhesive capsulitis
shoulder
Lower limb orthopaedic conditions

Box 23 will help in the diagnosis of conditions of the lower limb.
Box 23 Orthopaedic conditions of the lower limb
Locked knee, with positive McMurrays test Meniscal tear

Excessive anterior glide of tibia on femur Anterior cruciate ligament tear/rupture
Typically a sport injury: non-contact

deceleration with twisting in valgus position
(e.g. skiing, basketball, football)
Excessive posterior glide of tibia on femur Posterior cruciate ligament tear/rupture

Less common: may be significant trauma
pushing tibia back (e.g. against dashboard
in RTA, football tackle from in front, fall on
flexed knee)
Prominent tender tibial tubercle OsgoodSchlatters disease
Painful soles of feet Plantar fasciitis

Look out for associated diseases
(e.g. ankylosing spondylitis)
Elderly patient unable to weight-bear after fall Fracture neck of femur

Shortened and externally rotated leg
Pain over dorsum foot/metatarsal March fracture (metatarsal)

Athlete, history of excessive walking
Usually children/adolescents Ewings sarcoma

Long bones, limb girdle
Onion-peel sign
Usually adolescent Osteosarcoma

Older peak (in patients with Pagets)
Periosteal elevation (Codmans triangle)
Red eye 271
Red eye
The many causes of red eye are summarized in Box 24.
Box 24 Interpreting red eye
Blurred vision, haloes Acute closed-angle glaucoma

Hazy cornea
Pupil fixed and dilated
Raised intraocular pressure
Blurred vision, photophobia Anterior uveitis

Inflammatory cells
May be autoimmune disease
Vision normal, injected conjunctiva Bacterial conjunctivitis

Mucopurulent/lid crusting if bacterial
Usually bilateral, watery eyes Viral conjunctivitis

Preceding viral illness
Follicles on conjunctiva
Bilateral itchy eyes Allergic conjunctivitis

History of atopy (e.g. asthma, eczema)
History of trauma/contact lens use Corneal ulceration

Pain, photophobia, blurred vision
Pain, photophobia Dendritic ulcer (HSV)

May have history of other HSV infection
(e.g. cold sores)
Fluoroscein stain: branch-like lesion
Pain, hypopyon, ppvision Endophthalmitis

Usually after ophthalmic surgery
Retinal signs
Retinal signs are listed in Box 25.
Box 25 Interpreting retinal signs
Silver wiring, AV nipping, cotton wool spots, Hypertensive retinopathy

flame/dot blot haemorrhages
Hard exudates, microaneurysms, haemorrhages, Diabetic retinopathy
macular oedema
Stormy sunset appearance Central retinal vein occlusion
Cherry red spot at macula Central retinal artery occlusion
Optic disc cupping Glaucoma
Blurred, elevated disc swelling Papilloedema
Absent venous pulsations
Associated raised intracranial pressure
Bone spiculing Retinitis pigmentosa
Loss of red reflex Cataract
Mozzarella pizza appearance CMV retinitis
History of immunocompromise (e.g. HIV)
Pupils 273
Pupils
Pupilar signs are listed in Box 26.
Box 26 Interpreting pupilar signs
Bilateral dilated pupils Brainstem death

Plus no vestibulo-ocular reflex Amphetamines, cocaine
Plus euphoric Tricyclic antidepressant overdose
Plus anticholinergic signs
(e.g. qpulse, pBP, urinary retention)
Bilateral pinpoint pupils Opiate overdose
Pontine haemorrhage
Dilated pupil Cranial nerve III lesion
Ptosis, down-and-out pupil HolmesAdie pupil
Young woman, sluggish reaction to light,
may have ptendon reflexes
Constricted pupil Neurosyphilis
Irregular pupils, reacts accommodation Diabetes (ArgyllRobertson pupil)
but not light
Unilateral ptosis, ipsilateral loss sweating Horners syndrome
(anhidrosis)
Ocular movements
Ocular signs are listed in Box 27.
Box 27 Interpreting ocular movements
Lesion Ocular movement
Cranial nerve III Defective elevation, depression, adduction

Cranial nerve IV Defective depression in adduction
Vertical diplopia worse in down gaze
Cranial nerve VI Failure to abduct
Horizontal diplopia worse on abduction
Visual field defects 275
Visual field defects

Features of visual field defects are listed in Box 28.
Box 28 Visual field defects
Clinical finding Diagnosis
Bitemporal hemianopia Chiasma lesion (e.g. pituitary tumour)

Superior quadrantanopia Temporal lobe lesion
Inferior quadrantanopia Parietal lobe lesion
Homonymous hemianopia Optic radiation, visual cortex injury
Central scotoma Macula (degeneration/oedema)
Hypertensive retinopathy
Hypertensive retinopathy is given a grading (see Box 29).
Box 29 Grading of hypertensive retinopathy
Grading Features
I Silver wiring
II AV nipping
III Grade II haemorrhages, cotton wool spots, exudates
IV Grade III plus papilloedema
Diabetic retinopathy 277
Diabetic retinopathy
Retinopathy in diabetes is staged (see Box 30).
Box 30 Stages of diabetic retinopathy
Stage Features
Background Microaneurysms, hard exudates, flame/dot

haemorrhages
Maculopathy Background macular retinopathy
Pre-proliferative Maculopathy cotton wool spots, blot
haemorrhages, venous beading
Proliferative Pre-proliferative neovascularization of
disc/retina
Neurosurgery/head injury
Some features of head injury likely to come up in EMQs are listed in Box 31.
Box 31 Features of head injury or pathology
Head injury or pathology Features
Subdural haemorrhage History of trauma

Particularly elderly/alcoholic in EMQ
C T: white crescentic lesion concave to skull
Extradural haemorrhage Usually clear history of significant head trauma
Lucid interval
C T: white lesion convex (lentiform shape) to skull
Basal skull fracture Anosmia, rhinorrhea
Periorbital bruising (racoon eyes)
Bruising behind ear/haemotympanum
Diffuse axonal injury Significant head injury, comatosed but normal C T
Subarachnoid haemorrhage Sudden-onset severe debilitating headache
Meningism (e.g. neck stiffness)
Lumbar puncture: xanthochromia
Arterial blood gases 279
Arterial blood gases

When interpreting blood gases one should identify whether an acidosis or alkalosis
is present, and then look for a metabolic or respiratory cause for the derangement
and consider compensatory mechanisms. In addition to information on the patients
acid/base status, the blood gas will give information on oxygenation, electrolyte
values and glucose and lactate levels (see Boxes 32 and 33). The normal ranges for
arterial blood gases are:
pH: 7.357.45
PCO2: 4.276.4 kPa
PO2: 11.114.4 kPa
HCO 3 : 2428 mmol/L
Acid/base excess (ABE): 2
Glucose: 3.95.3 mmol/L
Lactate: 0.51.6 mmol/L
Box 32 Expected directional changes in blood gas results for various conditions
Imbalance pH PCO2 HCO

3 ABE
Respiratory acidosis p qq N N
Partially compensated p q qq qq
Fully compensated N q q q
Respiratory alkalosis q pp N N
Partially compensated q p pp pp
Fully compensated N p p p
Metabolic acidosis p N pp pp
Partially compensated p pp p p
Fully compensated N p p p
Metabolic alkalosis q N qq qq
Partially compensated q qq q q
Fully compensated N q q q
N, normal
Classical EMQ descriptions of blood gases
Box 33 Classical EMQ descriptions of blood gases
Condition Features
Respiratory alkalosis Anxious, hyperventilating, signs of acute

hypocalcaemia
(e.g. perioral paraesthesia, numbness, tingling)
Respiratory acidosis Scenario with reduced respiratory effort
(e.g. neuromuscular disease, COPD)
Metabolic acidosis Diabetic ketoacidosis scenario, especially in
undiagnosed diabetic, septic patient, renal
failure
Metabolic alkalosis Pyloric stenosis scenario in vomiting infant,
purgative/laxative abuse
Skin cover in plastic surgery 281
Skin cover in plastic surgery

Aspects of skin cover are listed in Box 34.
Box 34 Skin cover
Use Type
Infected wound, cosmesis not important Secondary intention

(e.g. post-incision and drainage of buttock abscess)
Clean small wound not under tension Primary intention
Skin cover required Split-thickness skin graft

Can cover large areas (e.g. skin cover for burns,
resurface muscle flaps)
May be poor cosmesis
Needs good care of donor site
Smaller area skin cover Full-thickness skin graft

Better cosmesis so good for facial defects
More resistant to trauma so can use on body
areas subject to abrasion
Defect too large to close, or graft not possible Flap (local/pedicled/free)

(e.g. compound lower limb fracture)
Reconstruction surgery (e.g. breast)

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SECTION 10: EMQ REVISION

Colicky loin pain radiating to groin Ureteric colic

Weight loss, anaemia, dysphagia Oesophageal carcinoma

Middle-aged woman presents with: Primary biliary cirrhosis

Usually middle-aged male: Primary sclerosing

Chronic liver disease

Chronic liver disease associated with:

Pyloric stenosis Projectile vomiting

X-ray feature Condition

Free air under diaphragm Perforated viscus (e.g. diverticulum/

Inflammatory bowel disease

Can affect anywhere between mouth and anus Crohns disease

Only affects colon Ulcerative colitis

Skin lesion EMQ feature

Sebaceous cyst Punctum

Thyroid cancer Features

Follicular carcinoma Usually woman and solitary lesion

Thyroid condition EMQ features

Hashimotos thyroiditis Hypothyroid symptoms with goitre

USS Evaluation of hydronephrosis, hydroureter

Calculus Incidence Associations

Calcium oxalate 75 per cent Alkaline urine

Lump in the groin

Hydrocoele Yes No Yes

Diagnosis Duration Tinnitus Loss of hearing Precipitant factors

Box 15 Some causes of sore throat

Diagnosis General Speech Trismus Appearance Neck Bloods

Quinsy Yes Hot Yes Unilateral palatal Enlarged qWCC,

Tonsillitis Yes Normal No Bilateral tonsil Enlarged qWCC,

Glandular Yes Normal No Bilateral tonsil Massive qWCC,

Acid reflux No Normal No Normal Normal Normal

Tonsil No Normal No Unilateral tonsil Nodal May be raised

Diagnosis True Regurgitation Neck Referred Other

Globus No No No No Anxiety, lack of positive findings

Thyroid goitre Yes, if large No Antero-inferior, No Sudden increase in size and

Diffuse oesophageal Yes No No No Associated chest pain and corkscrew

Bulbar palsy Yes No No No Poor cough dysphonia dysarthria

Diagnosis Site Moves on Moves on Other EMQ

Thyroglossal Typically midline Yes Yes May become infected

Branchial cyst Lateral neck just No No Transilluminates

Chemodectoma Lateral neck, No No Pulsatile and mobile

Submandibular Below ramus No No Bimanually palpable

Parotid Parotid region, No No VII nerve palsy in cases of

Cystic hygroma Posterior triangle No No Often young patient

The paediatric hip

Congenital dislocation of hip Usually detected at birth by

Perthes disease Usually male

Slipped femoral epiphysis Often obese

Upper limb nerve injury

Nerve implicated Features

Median nerve Wasting at thenar eminence

Ulnar nerve Wasting at hypothenar eminence

Radial nerve Weakness of wrist extension leading to wrist drop

Axillary nerve Failure of abduction after shoulder dislocation

Long thoracic nerve Winged scapula

Klumpkes palsy (C8, T1) Paralysis of intrinsic muscles of the hand

Lower limb nerve injury

Nerve implicated Features

Common peroneal nerve Often, blow to lateral aspect of knee is described

Tibial nerve Inability to invert foot or stand on tiptoe

Sciatic nerve Foot-drop (e.g. after hip replacement)

Reflexes and motor nerve roots

Reflex/movement Nerve root

Upper limb orthopaedic conditions